MCHF Bullying Report Form
Students are asked to complete the form to make a formal bullying report. Students are asked to remember that bullying is defined as repeated acts by another individual that affects the student in a negative and degrading manner.

Students are to ensure that their parents are aware of this formal report being made. Students primary can have their parents complete this form on their behalf.

Student Name
Your answer
Name any witnesses
Your answer
Name of student/s that bullied you?
Your answer
Description of the bullying that is occurring
Provide as much information and details as possible.
Your answer
How did the bullying make you feel?
Explain your emotions, thoughts and feelings.
Your answer
Has this bullying been reported before?
If you answered 'YES' to the previous question, how did you feel after it was resolved?
Worried Still
Extremely Confident
If you have previously reported the bullying, who was the report made to?
Your answer
Student Authorisation
Provide the name of the student submitting this form to authorise the contents provided.
Your answer
Parent Authorisation
Provide the name of the parent who is aware of the report being submitted.
Your answer
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